A 75-year-old man with hypertension and benign prostatic hypertrophy was admitted to the hospital 5 days ago because of acute deep venous thrombosis of his right lower extremity. Current medications include intravenous heparin, warfarin, enalapril, and terazosin. He is 179 cm (5 ft 8 in) tall and he weighs 66 kg (145 lb); BMI is 22 kg/m2. Vital signs are temperature 37.1°C (98.8°F), pulse 75/min, respirations 17/min, and blood pressure 147/85 mm Hg. Lungs are clear to auscultation. Cardiac examination discloses no abnormalities. There is 1+ edema of the right lower extremity and presence of varicose veins bilaterally. The patient ambulates without difficulty and has good oral intake. Results of laboratory studies obtained today are shown:
Serum Blood
Creatinine 1.7 mg/dL Hemoglobin 14.1 g/dL
Na+ 140 mEq/L Platelet count 165,000/mm3
K+ 4.5 mEq/L PT 18 seconds
Cl− 108 mEq/L PTT 60 seconds
HCO3− 26 mEq/L INR 2.5
Glucose 100 mg/dL
Which of the following is the most appropriate management at this time?
A) Continuation of intravenous heparin therapy in the hospital
B) Discharge with warfarin therapy
C) Discontinuation of all anticoagulation therapy and observation
D) Placement of an inferior vena cava filter
E) Switch to low molecular weight heparin outpatient treatment
A 50-year-old plumber is admitted to the hospital through the emergency department because of hematemesis that began at home following dinner 1 hour ago. Medical history is significant for mild epigastric pain, for which he has not sought care. He has not had weight loss, but he occasionally has had dark stools. He takes hydrochlorothiazide for hypertension and over-the-counter ibuprofen for lumbar pain. He has no family history of gastrointestinal problems. None of his family members at home are ill. He recently worked on a clogged sewer line in a large chemical plant. He returned home 7 days ago from a vacation to a resort in Mexico. He drinks two beers nightly. The patient is 183 cm (6 ft) tall and weighs 91 kg (200 lb); BMI is 27 kg/m2. Vital signs on admission are temperature 36.1°C (97.0°F), pulse 110/min, respirations 20/min, and blood pressure 100/60 mm Hg. The patient is in no distress. Physical examination discloses lumbar paraspinal spasm and crepitus of both knees. Fluid resuscitation was initiated in the emergency department. An image obtained during endoscopy is shown.
Which of the following is the most significant risk factor for development of this patient's condition?
A) Alcohol consumption
B) Chemical exposure
C) Occupation
D) Travel to Mexico
E) Use of ibuprofen
e? waiting for the answer